so many people don't know their own diagnosis
...and yet they continue to see their therapist. Does it not seem crazy that most of these clients cannot state what their therapist has been treating?! From these clients, the best I hear is nearly always 'My hips are out of alignment' or 'I've got one leg slightly shorter than the other.' Well... so what?
Gurney (2002) reviewed leg length discrepancy and suggested it does not need treating in all cases, with 20mm often used as the 'breakpoint'. Two centimetres! That's not a small amount. Furthermore, Gross (1978) conducted a survey in which all patients with a leg length discrepancy between 15 and 20mm 'did not consider their short leg to be a problem in any way.'
Based on a review published in 2005, 90% of the population has some anatomic leg length discrepancy (average 5.2mm), although this figure hugely varies between studies. Seven of the studies reviewed identified whether participants were symptomatic (LBP or knee/hip problems) or asymptomatic (varying from last 6 months to ever) ...and guess what? The mean leg length discrepancy between the two groups differed by 0.1mm (symptomatic mean 5.1mm, SD 3.9; asymptomatic mean 5.2mm, SD 4.2).
This isn't new information. The studies used in the above review were conducted between 1970 and 2005. Soukka et al (1991) measured leg length using radiographs in 247 participants between the ages of 35-54 years. 78 of these participants had disabling low back pain during the previous twelve months and a mean leg length discrepancy of 5.3mm (maximum 17mm). However, a further 53 participants also had a discrepancy (mean 5.5mm, maximum 20mm) but... wait for it... absolutely no history of low back pain.
Then, in 2006, 126 of 1,100 military cadets were identified to have lower limb discrepancy over 0.5cm. Over the following year there was no difference in incidence of injury between those with discrepancies and those without (Goss et al, 2006). Furthermore, gait asymmetry and effects on kinetics and kinematics are only present in discrepancies over 2cm (Kaufman et al, 1996).
Furthermore, accurate measurement of a leg length discrepancy requires the use of radiographic imaging.
However, amongst these studies, there is evidence that leg length discrepancies are linked to increasing your chances of some injuries. Lower limb stress fractures have been shown to be of higher incidence in those with discrepancies. This is also true of trochanteric bursitis, patellar apicitis, and patellofemoral syndrome amongst many others. However, there are also studies that state leg length discrepancies have little to no effect. And on an interesting side note, there are differing conclusions as to whether leg length discrepancies would predict or be the result of knee and hip OA (intriguingly this is predominantly in the longer leg, rather than the shorter).
Basically, there remains huge debate as to the effects and clinical relevance of leg length discrepancy. It is logical for there to be pelvic torsion when one leg is longer than the other, however there is inconclusive evidence to use leg length discrepancy and hip misalignment as a diagnosis for pain - especially for an acute issue. If using leg length discrepancy as a diagnosis, why not investigate whether there is piriformis malfunction, OA, plantar fasciitis or one of the many other questioned associated pathologies? With treatment for leg length discrepancy (such as foot lifts or surgery) recommended only for those with >2cm difference, manual therapies and exercise prescription are commonly looked to for those with <2cm difference. Clients should be questioning exactly how manual therapies are going to benefit their leg length discrepancy, or whether therapy is instead for an effect of their leg length discrepancy (that is, if the issue is related at all).
References
Goss, D. L., Moore, J.H., Slivka, E. M. and Hatler, B. S. (2006) 'Comparison of injury rates between cadets with limb length inequalities and matched control subjects over 1 year of military training and athletic participation' Military Medicine 171(6), pp. 522-525.
Gurney (2002) reviewed leg length discrepancy and suggested it does not need treating in all cases, with 20mm often used as the 'breakpoint'. Two centimetres! That's not a small amount. Furthermore, Gross (1978) conducted a survey in which all patients with a leg length discrepancy between 15 and 20mm 'did not consider their short leg to be a problem in any way.'
Based on a review published in 2005, 90% of the population has some anatomic leg length discrepancy (average 5.2mm), although this figure hugely varies between studies. Seven of the studies reviewed identified whether participants were symptomatic (LBP or knee/hip problems) or asymptomatic (varying from last 6 months to ever) ...and guess what? The mean leg length discrepancy between the two groups differed by 0.1mm (symptomatic mean 5.1mm, SD 3.9; asymptomatic mean 5.2mm, SD 4.2).
This isn't new information. The studies used in the above review were conducted between 1970 and 2005. Soukka et al (1991) measured leg length using radiographs in 247 participants between the ages of 35-54 years. 78 of these participants had disabling low back pain during the previous twelve months and a mean leg length discrepancy of 5.3mm (maximum 17mm). However, a further 53 participants also had a discrepancy (mean 5.5mm, maximum 20mm) but... wait for it... absolutely no history of low back pain.
Then, in 2006, 126 of 1,100 military cadets were identified to have lower limb discrepancy over 0.5cm. Over the following year there was no difference in incidence of injury between those with discrepancies and those without (Goss et al, 2006). Furthermore, gait asymmetry and effects on kinetics and kinematics are only present in discrepancies over 2cm (Kaufman et al, 1996).
Furthermore, accurate measurement of a leg length discrepancy requires the use of radiographic imaging.
However, amongst these studies, there is evidence that leg length discrepancies are linked to increasing your chances of some injuries. Lower limb stress fractures have been shown to be of higher incidence in those with discrepancies. This is also true of trochanteric bursitis, patellar apicitis, and patellofemoral syndrome amongst many others. However, there are also studies that state leg length discrepancies have little to no effect. And on an interesting side note, there are differing conclusions as to whether leg length discrepancies would predict or be the result of knee and hip OA (intriguingly this is predominantly in the longer leg, rather than the shorter).
Basically, there remains huge debate as to the effects and clinical relevance of leg length discrepancy. It is logical for there to be pelvic torsion when one leg is longer than the other, however there is inconclusive evidence to use leg length discrepancy and hip misalignment as a diagnosis for pain - especially for an acute issue. If using leg length discrepancy as a diagnosis, why not investigate whether there is piriformis malfunction, OA, plantar fasciitis or one of the many other questioned associated pathologies? With treatment for leg length discrepancy (such as foot lifts or surgery) recommended only for those with >2cm difference, manual therapies and exercise prescription are commonly looked to for those with <2cm difference. Clients should be questioning exactly how manual therapies are going to benefit their leg length discrepancy, or whether therapy is instead for an effect of their leg length discrepancy (that is, if the issue is related at all).
References
Goss, D. L., Moore, J.H., Slivka, E. M. and Hatler, B. S. (2006) 'Comparison of injury rates between cadets with limb length inequalities and matched control subjects over 1 year of military training and athletic participation' Military Medicine 171(6), pp. 522-525.
Gross, R. H. (1978) 'Leg length discrepancy: how much is too much?' Orthopedics 1(4) pp. 307-310.
Gurney, B. (2002) 'Leg length discrepancy' Gait & Posture 15 pp. 195-206.
Kaufman, K.R., Miller, L.S., Sutherland, D. H. (1996) 'Gait asymmetry in patients with limb-length inequality' Journal of Paediatric Orthopaedics 16 pp. 144-150.
Knutson, G. A. (2005) 'Anatomic and functional leg-length inequality: A review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance' Chiropractic & Osteopathy 13(11)
Soukka, A, Alaranta, H, Tallroth, K and Heliovaara, M (1991) 'Leg-Length Inequality in People of Working Age: The Association Between Mild Inequality and Low-Back Pain Is Questionable' Spine 16(4).
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